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RCGPNI LGBT patient guideline

Guidelines for the care of lesbian, gay, bisexual, and trans patients in primary care

Care of LGB patients in primary care

Lesbian, gay, and bisexual (LGB) patients face minority pressure, stigmatisation, and the pressure of ‘coming out’ on a daily basis. They have higher rates of depression, self-harm and suicide. They are more likely to smoke, take alcohol to excess, and take illegal drugs. Their complex needs in primary care go far beyond sexually transmitted infection (STI) screening

Consultation issues

There are a number of ways a practice can demonstrate an open and inclusive clinical environment to lesbian, gay, bisexual, and transgender (LGB and T) patients:

allow LGB and T patients to self-identify on new patient enrolment forms if they choose to do so

practices could consider how they record or code that patients are LGB and T after gaining consent to do so from the patient

reception staff should demonstrate positive attitudes and use sensitive language

sexual orientation training could be considered for all primary care staff

posters and leaflets reflecting LGB and T issues can be displayed in the waiting room

sexual orientation and gender should be included in the anti-discrimination policy and it should be clearly displayed

include LGB and T patients in patient participation groups

During a consultation, it is important not to make assumptions about a patient’s sexual orientation or to assume they are heterosexual. It is important to facilitate disclosure but also to respect non-disclosure

A GP can make it easier for patients to disclose or talk about their sexual orientation by:

assuring the patient that consultations are confidential

adopting a non-judgemental attitude

using open questions such as ‘Do you have a partner?’

using gender-neutral, inclusive terminology

Where a patient chooses to disclose their sexual orientation as LGB it is important that this is acknowledged and the terms they use are clarified

Health screening

Cervical smear

Lesbian and female bisexual patients are less likely to have had a cervical smear than women in general

GPs and GP employed nurses should:

offer all women aged 25–64 a cervical smear regardless of their sexual orientation

ask inclusive questions when history taking around the smear test, e.g. ‘Are you sexually active at present?’ and if yes, ‘Do you have a regular partner?’ making sure not to assume heterosexuality

Breast cancer

Lesbian and bisexual women aged 50–79 years are more likely to develop breast cancer than women in general—despite having similar rates of breast screening to the general population in that age group

GPs and GP employed nurses should educate all eligible women about breast screening and breast awareness, regardless of their sexual orientation

Substance misuse

The LGB and T population use all types of illegal drugs more than the general population. The reasons for higher substance misuse appear to be multifactorial

The disparity between levels of substance misuse in the LGB and T population and the general population are highest in the 15–24 year old age group. LGB and T people are also less likely to access substance misuse services, often for fear of discrimination

GPs and GP employed nurses should be aware:

of the higher rate of substance misuse in the LGB and T population

that LGB and T people may find it more difficult to seek help and access services

Alcohol

GPs and GP employed nurses should be aware:

of the higher rate of alcohol use in the LGB and T population and screen as felt appropriate

Mental health

GPs should:

be aware of the increased risk of depression, self-harm, and suicidal ideation in LGB and T patients and screen patients for mental health risk factors if appropriate

recognise that conversion therapy is ineffective, inappropriate, and potentially damaging

Sexual health

GPs providing sexual health services to LGB patients should:

only practice STI screening and management within their own level of competency and training. If GPs feel out of their depth—refer or sign post to Genito-Urinary Medicine (GUM) services

be able to take an appropriate and confidential sexual history to assess risk of STIs in patients of all sexual orientations

be mindful that women who have sex with other women (WSW) or men who have sex with other men (MSM) may not always identify as L, G, or B

offer STI testing on the basis of risk rather than sexual orientation

be aware that if the patient is symptomatic they need to be offered a genital examination or referred to GUM

check if the patient needs assistance in accessing an appointment with GUM services and act as an advocate if appropriate

make themselves aware of their local level 3 GUM service and community based services, which can offer some STI testing—such as Brook clinic (male <25,female <20), The Rainbow Project (male only), outreach testing in gay venues, and walk-in MSM clinics in GUM

When taking a sexual history you should consider the following guidance:

ask to see the patient alone as this will reduce embarrassment and enhance disclosure

obtain consent and warn about the nature of the questions, e.g. ‘I need to ask you some personal questions to help me advise you on the correct STI tests for you, would that be ok?’

normalise the process, e.g. ‘We ask these questions to everyone with similar symptoms/difficulties’

be non-judgemental and emphasise confidentiality

try not to make assumptions about sexual practice or risk of STIs before you ask the questions

avoid the terminology of LGB unless the patient identifies as such

the language used should be professional but can be individualised for the patient or health practitioner

STI screening should not necessarily be the first thing the clinician offers when a patient ‘comes out’. In order to understand the risks a patient might be taking it is important to take a more holistic view of their health. Engaging in high sexual risk behaviour may be an indication of other underlying problems, such as deteriorating mental health, social exclusion, or substance misuse

Men who have sex with men (MSM)

All MSM should be offered a three series course of hepatitis A and B vaccinations free on the NHS. It is important that GPs and GP employed nurses differentiate between these vaccinations schedules and travel vaccinations

GPs should be aware that MSM patients:

should ideally be managed at a level 3 GUM service (consultant led)

could be offered opportunistic HIV testing in primary care

having unprotected sex with casual or new partners should have an HIV/hepatitis B and C/syphilis/STI screen at least annually, or every 3 months if changing partners regularly

may require triple site (urine, pharyngeal, and anal) testing for chlamydia and gonorrhoea based on sexual practice

should be offered a free accelerated course of hepatitis A and B vaccination and booster based on immunity

Post-exposure prophylaxis (PEP)

As a GP or GP employed nurse you should:

be able to assess the patient’s risk of HIV exposure in the preceding 72 hours or contact GUM for advice

refer at-risk patients to GUM urgently for same day assessment if you believe PEP should be discussed

refer the patient to A&E for PEP if it is out of hours for GUM

Lesbian and bisexual women and sexual health

Lesbian and female bisexual patients often report they do not feel at risk of STIs, are too scared to get tested, or have been told by a healthcare worker that they do not need tested. Not all WSW will identify as L, G, or B. Patients that identify as L or B may be having or have had sex with a man in the past. Conversely, women who identify as heterosexual may be having sex or have had sex with a woman

LB women have both oral and penetrative sex and can share fluids through hands, mouth, and sex toys. Although bacterial vaginosis (BV) can occur without sexual contact it is commonly sexually transmitted between LB women. Thrush can also be transmitted by sexual contact in LB women

All STIs can be transferred between women. LB patients can get pelvic inflammatory disease (PID) most commonly from chlamydia infection. Given the risks of untreated PID, suspected PID should be treated

Fertility issues

LB women may present requesting referral to fertility clinics. The NHS can help with donor insemination or in vitro fertilisation but this is very limited. To be eligible, the patient will need to be trying to get pregnant without medical help for at least two years and it must be proven that the patient has a medical condition that makes conception difficult

Many LB women choose self-insemination to conceive. This raises issues of safety and the health of the sperm donor

Care of trans patients in primary care

Terminology

Transgender/trans—an umbrella term for people whose gender identity and/or gender expression differs from the sex assigned to them at birth. This term can include many gender identities such as: transsexual, transgender, androgynous, gender-queer, gender variant, or differently gendered people. Trans people may or may not decide to alter their bodies hormonally and/or surgically

Key considerations

Be understanding. A negative reaction can do serious harm

Get names and pronouns correct (ask discreetly if necessary)

Be aware of the importance of medical confidentiality

Refer to the appropriate gender service:

child and adolescent

adult

Be cognisant that co-existing health issues may not be linked to gender issues

Support the treatment set out by gender service

Consider signposting to sources of support within the community and voluntary sectors, detail available throughwww.transgenderni.com

What is gender dysphoria?

Gender and sexual orientation are different

It is not unusual for gender variance to present during early childhood or puberty

Your role as the GP

Onward referral to a Gender Identity Service is appropriate for anyone who experiences gender dysphoria

Patients should be recognised as the gender with which they identify and have the same rights, including access to physical and mental health services, as any other patient

A shared care arrangement between the GP practice and the gender service for the initiation and ongoing monitoring of hormones provides the best and safest practice based on current guidelines

Over the course of their lifetimes, Trans patients are at much higher risk of negative mental health, self-harm and suicide than the general population

Royal College of General Practitioners Northern Ireland. Guidelines for the Care of Lesbian, Gay and Bisexual Patients in Primary Care. 2015. Royal College of General Practitioners Northern Ireland. Guidelines for the Care of Trans Patients in Primary Care 2015 First included: May 2016.

Shelley Raine explains why the UKMEC is so important in general practice and how to apply the recommendations when seeing women, both for the initiation of a contraceptive method and continuation of a treatment.